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The Nutty Way to Treat Depression

Detail from The Extraction of the Stone of Madness by Hieronymus Bosch (c. 1488 – 1516)

Depression is a symptom, not a diagnosis. That is not to say that a depressed person does not experience real suffering, but when does normal human misery become a mental illness? Clearly, it is a matter of degree. I have seen patients in hospital overwhelmed by depression who were unable to do anything for themselves – even get out of bed.

As I have discussed before, antidepressant medicines do seem to help some people, and I occasionally prescribe them myself.

However, the notion that depression is due to a chemical imbalance in the brain is nothing more than a theory. Any indirectly observed or inferred changes in the levels of serotonin, dopamine or other brain neurotransmitters may be the result, rather than the cause, of the symptoms.

How do antidepressants work? The short answer is that we do not know. They are empirical, that is, trial-and-error, treatments. Further, if you take an antidepressant you feel something – commonly dizziness, weakness or drowsiness. These are side-effects of the drug though they may be mild and usually diminish as patients get used to them. Many patients find these symptoms a small price to pay for feeling less depressed. Could this be a placebo effect? You can tell the drug is doing something and you hope and expect to feel better, so you do.

Even if we accept that depression is associated with some kind of imbalance of neurotransmitter chemicals, is it desirable or safe to compound this with an additional disturbance of brain chemistry by the use of drugs? It should be kept in mind that the way antidepressants produce side-effects is through causing a drugged state affecting the brain.

This being so, how much more cautious should we be about using drugs which are well known to cause major disturbances in the brain and which can and do result in psychoses. I am referring to hallucinogenics: LSD, mescaline, psilocybin and the like.

Yet this is what is actually being proposed by the well-named Professor David Nutt, who was dismissed in 2009 as chair of the government’s Advisory Council on the Misuse of Drugs for saying that ecstasy, cannabis and LSD are less dangerous than alcohol and tobacco.

He is back in the news after having treated a small number of patients with ‘resistant depression’ with psilocybin and now wants to carry out a larger trial using this dangerous drug. Incidentally, Professor Nutt works in collaboration with Amanda Feilding, whom I’ve met, who in 1970 drilled a hole through her skull (trepanation) in an attempt to enhance her level of consciousness.

Such procedures are reminiscent of the era of drastic – even heroic – physical treatments for mental illnesses: insulin coma therapy, electro-convulsive therapy (ECT) and lobotomy. These are now rightly discredited except for ECT which is still occasionally used for severe depression.

Is the pendulum swinging too far? It is all very well doing research into the physical underpinnings of mental illnesses and thereby to try and find more effective treatments. But the pioneering efforts of around one hundred years ago, when Sigmund Freud and C G Jung looked into the psychological causes of mental illness, should not be forgotten.

Text © Gabriel Symonds

This entry was posted in C G Jung, Freud, Medical, Psychiatry and tagged Amanda Feilding, Beckley Foundation, David Nutt, depression, LSD, psilocybin, trepanation on October 5, 2016 by Gabriel Symonds. Edit

Messing up your brain

 

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It has long been suspected that regular use of cannabis (marijuana), especially the high potency variant called ‘skunk’, can increase the risk of psychosis in vulnerable people.

And now Sir Robin Murray, professor of psychiatric research at King’s College London, rightly says ‘It’s not sensible to wait for absolute proof that cannabis is a component cause of psychosis.’ He adds ‘There’s already ample evidence to warrant public education around the risks of heavy use of cannabis, particularly the high-potency varieties. For many reasons, we should have public warnings.’

This view is echoed by a government spokesperson: ‘We must prevent drug use in our communities and help people who are dependent to recover, while ensuring our drugs laws are enforced. There is clear scientific and medical evidence that cannabis is a harmful drug which can damage people’s mental and physical health, and harms communities.’ (The Guardian, 15 April 2016.)

With this preamble, let me get to my theme: the treatment of depression.

There is no doubt that in extreme cases the illness called major depressive disorder can be devastating. I have seen patients reduced to a state of complete immobility, unable to work or even get out of bed because of overwhelming unhappiness. These, however, are a minority. The vast majority of people who have been labelled as suffering from a depressive ‘disorder’ have what might better be called normal human misery.

There are no blood tests or other objective criteria for making the diagnosis; it is made entirely on symptoms or observations such as these:

Depressed mood most of the day, nearly every day…Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day…Significant weight loss when not dieting or weight gain…Insomnia or hypersomnia (excessive sleepiness) nearly every day…agitation…Feelings of worthlessness or excessive or inappropriate guilt…Diminished ability to think or concentrate…Recurrent thoughts of death…recurrent suicidal ideation…or a suicide attempt or a specific plan for committing suicide…(Diagnostic and Statistical Manual of Mental Disorders, 5th edition, 2013, American Psychiatric Association.)

These are pretty serious symptoms, but they are all subjective and need to be interpreted. How do you decide when a symptom is ‘marked’ or ‘significant’? There is a risk that people suffering from normal extreme sadness, such as after a bereavement, may be misdiagnosed as having a depressive disorder because the symptoms have lasted longer than the American Psychiatric Association deems appropriate. (There is a whole book dealing with this very problem: The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, by A V Horwitz and J C Wakefield,  OUP 2007.)

Such a view is echoed in an article on this same problem in The British Medical Journal (9 December 2013) on ‘medicalising unhappiness’ which noted:

Over recent decades there has been an increasing tendency, especially in primary care, to diagnose depression (commonly major depressive disorder) in patients presenting with sadness or distress and offer them antidepressant medication.

Many patients report sadness or distress during consultations with primary care doctors. Such emotions may be related to grief and other life stresses, including the stress of physical illness. Sometimes sadness appears out of the blue, without obvious relation to external causes.

Without a doubt, depression is real and horrible and deserving of the highest standards of medical care.

What to do about it? Rather than reaching for the prescription pad, it might be better to listen to the patient. He or she, if given the chance in a supportive,  non-judgemental environment, nearly always has got plenty to say – attesting to the importance of the psychological causes of depression.

If the doctor does decide a prescription is warranted, it should be understood by both parties that this is empirical treatment. The fond idea that antidepressant correct a ‘chemical imbalance in the brain’ is purely hypothetical. Such imbalances, if they exist, could well be the result rather than the cause of the depression. Antidepressants, nonetheless, can be helpful to tide a patient over a difficult patch, but they are not a cure. Do they work? They appear to work in some people, but it is unpredictable. Some patients, especially those with more severe degrees of depression, may find it preferable to be in the drugged state which antidepressants induce than to suffer their unmedicated distressing feelings; the same applies to people with severe anxiety and agitation. (See my blog of 1 May 2016, http://nicotinemonkey.com/?p=329 )

Further, psychiatrists, although their skills may be helpful in choosing a drug for those patients whose unhappiness is deemed serious enough to give it a try, should not be under any illusions about what they are doing. Antidepressants do not cure or even – in a strict sense – treat, depression. At best, they can help to reduce symptoms and thereby make life easier to bear.

This is all the more relevant in the light of a recent study on depression reported in The Lancet Psychiatry (http://dx.doi.org/10.1016/S2215-0366(16)30307-8) that there is a drug which is consistently effective in 35-40% of patients: it is called placebo.

Text © Gabriel Symonds

This entry was posted in Depression, Psychiatry and tagged antidepressants, cannabis, marijuana, placebo, psychosis, Sir Robin Murray, The Loss of Sadness on November 27, 2016 by Gabriel Symonds. Edit

Mental Illness Doesn’t Happen in a Vacuum

The fifth edition of the so-called bible of psychiatry, usually referred to as DSM-5, which means the Diagnostic and Statistical Manual of Mental Disorders, was published by the American Psychiatric Association in 2013. It contains an expanded list of diagnoses of mental illnesses compared with the 4th edition. I do not intend to enter into the controversy of whether many of the latest inclusions are real illnesses, or ‘disorders’ – as they are invariably called in this book.

Incidentally, it would read better, in my view, as well as making the book a lot shorter, if the word ‘disorder’ were dropped. For example, instead of shyness – yes, this is actually regarded as a mental illness – being called social anxiety disorder, why not just call it social anxiety? Schizophrenia is now schizoaffective disorder and drug abuse is labelled substance use disorder, etc. Well, no doubt psychiatry has moved on a bit since I did my psychiatric residency in the 1970s, but how much is due to real progress in understanding the causes of mental illness and how much is just a difference in nomenclature? It is true that many more drugs are now available, and very helpful they can be – particularly in the more severe forms depression and in psychoses (such as schizophrenia). However, it should be kept in mind that these are empirical treatments: they may work but how they work is speculative. The oft-quoted fond idea that such drugs adjust a chemical imbalance in the brain that is the cause of the disorder is unproven. There is no way at present to measure levels of serotonin, dopamine or other neurotransmitters in the living human brain, and anyway the alleged chemical imbalance may well be the result of the mental disturbance rather than the cause.

These thoughts came to mind recently after I read an autobiographical account of severe depression suffered by the late American author William Styron: Darkness Visible: A Memoir of Madness (1989). He is probably best known for his controversial novel, Sophie’s Choice. The experiences he describes are harrowing, but he eventually recovered after being admitted to a mental hospital. It seems the secure environment and empathy of the staff were the major factors in his recovery. He was not given ECT (electro-convulsive therapy) and there is little mention of drugs. But why did he become depressed? Brain disease? Probably, but what was the cause of that? Mr Styron tells us: he abused alcohol for forty years and was addicted to a sleeping tablet called Halcion which was unwisely prescribed long term and in high dose. Under these circumstances it is hardly surprising he became depressed. In addition, there was likely a psychological cause in that he lost his mother to cancer when he was only thirteen.

I regard the use of drugs in mental problems, not as a cure, but as a means of helping patients cope with a difficult time in their lives, and I do prescribe them when necessary. However, I believe it is just as important – if not more so – to try to help patients work through the underlying problems and repressed conflicts which are often involved in the cause of their distress.

This entry was posted in Medical on May 1, 2016 by Gabriel Symonds. Edit

Mental illnesses are brain diseases – or are they?

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There was a recent programme on the BBC consisting of sound bites about the latest so-called breakthrough in trying to understand mental illness – a field of medicine in which understanding is sorely lacking:

It’s pretty radical – that we can develop new treatment options that work through the immune system…It is ground-breaking…demonstrating that depression is a disorder of the whole body…really exciting advance…a challenge to the idea that mental illness is all in the mind

One patient describes the development of her psychosis: hallucinations, paranoid delusions and ending up in a catatonic state. She had a  brain biopsy and lumbar puncture and they found evidence of inflammation; she was diagnosed with auto-immune encephalitis. We are told that some doctors believe many more cases of mental illness could be due to an immune disease.

Caution is in order here. In some patients with extreme mental symptoms, inflammation of the brain was found and they had physical symptoms as well. This is not surprising. Many physical disorders can cause mental symptoms, for example delirium associated with high fever from infections with bacteria, viruses, malaria or syphilis; poisoning with many substances and drugs; physical degeneration of the brain in dementia, and so on. But just because an inflammatory cause has been found in these cases it doesn’t necessarily mean patients without physical symptoms will also turn out to have an identifiable disease of the brain.

In support of the ‘mental illness = brain disease’ hypothesis, we’re told it’s estimated that one in ten people with psychoses have antibodies indicating inflammation. Then what about the other nine of the ten?

In these particular patients with inflammation they used plasma exchange to remove the antibodies, gave intravenous immunoglobulin or prescribed steroids (cortisone). But it should be remembered that these are entirely non-specific treatments. Steroids themselves can even cause psychosis in some people. Steroid treatment, though it can be life-saving, has been likened to ‘kicking the telly when it’s on the blink’ – in the days of cathode-ray tube television sets.

Then the programme turns to depression. One sufferer gives this account:

My depression gets so bad that I can’t leave the bed, I can’t leave the bedroom, I can’t go downstairs and be with my partner and his two children. I can’t have the television on. I can’t have any noise, light. I have suicidal thoughts. I have self-harmed. I can’t leave the house and everything else just feels too much.

This is obviously a severe case, but of her history we are told nothing. Antidepressant drugs and psychological treatments like cognitive behavioural therapy may help some of these patients, but because so many don’t respond, researchers are now looking into ‘whether the immune system could be causing depression’ and whether ‘inflammation is actually the cause of the disease.’ They even wheel out a professor of ‘biological psychiatry’ (whatever that is) who says: ‘Maybe 30-40% of depressed patients have high levels of inflammation.’ This is pure speculation.

In any case, as I’ve asked before, how do you decide when normal human misery becomes a disease? Furthermore, some people without any symptoms may have ‘inflammatory markers’ in their bloodstream. Now they want to go on and ‘measure in the saliva stress hormones like cortisone and inflammation markers and look at the correlation with depression.’

Some of these scientists, in their efforts to develop an overarching biological theory of the cause of depression, almost get into contortions:

[In] individuals who have a history of early life trauma, even if they’ve never been depressed, there’s an activated immune system so they [are] at risk which then will lead to an increased risk of depression if the individual meets another [adverse] advent later in life.

This circular reasoning seems to be saying that if you suffer adverse events in early life you may be at increased risk of being depressed if you meet another adverse event later on.

An actual patient with depression appears in the film who says:

I had sertraline, Prozac, citalopram, duloxetine and metazoline , so I was on three at one point – it’s totally trial and error. (That’s the problem!)

To this, another scientist comments:

We’re not able to predict at the beginning whether someone will respond to one of the antidepressant’s that’s routinely prescribed. But we think by measuring inflammation in the blood we’ll be able to identify individuals who do require more complex, more intense antidepressant treatment, perhaps a combination of more than one antidepressant or antidepressant and anti-inflammatory or go straight into more complex treatments.

It’s all assumption and theory patched together.

Let’s consider depression a bit further.

Is depression a symptom or a disease? If it’s a disease how do you define it? The fact that some people with physical disorders become depressed is no reason for supposing that all or most cases of depression are also due to physical causes. Maybe it’s the depression itself which causes the immune disorder.

I think the pendulum has swung too far. In efforts to make psychiatry a discipline comparable with other medical specialties, a number of assumptions are being made that are extremely difficult to explain with the present state of our knowledge. Unlike, say, heart disease where there is a physical organ which can be investigated, in psychiatry the mind of the doctor is observing the mind of the patient. But what is the mind? Is it the same as consciousness? What is the source of the unconscious (in the Jungian sense)? How does the brain give rise to the perceived experiences of sensations and thoughts?

Let’s start – if it should be possible – with a provable definition of the mind and see where we go from there. Then, perhaps, we might begin to understand mental disorders.

Text © Gabriel Symonds

This entry was posted in C G Jung, Depression, Psychiatry and tagged antidepressants, autoimmune brain disease on November 23, 2016 by Gabriel Symonds

Medicine and manners

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I believe inter-collegial courtesy is of the highest importance in medical practice. If it is not observed it may have unfortunate consequences for the patient, as well as for the professionals involved. ‘Unfortunate’ is putting it mildly – it could have been fatal in the case I shall relate.

Some years ago a patient came to see me with massive bruising all down one side of his body. He was also suffering from symptoms of depression. In those days I was very busy with my general practice and didn’t have time to take on another patient for regular hour-long psychotherapy sessions. Therefore I referred him to a colleague, a woman lay therapist whom I knew and who had, I thought, quite a good reputation among the foreign population of Tokyo.

I heard nothing further until this patient turned up again three weeks later with the bruising. The story was as follows: the psychotherapist to whom I had referred him turned out not to have confidence enough to treat him herself; she referred him on to another practitioner, a Japanese psychiatrist. The psychiatrist, in the way that psychiatrists do, prescribed him an antidepressant. Unfortunately he omitted to take a work history, that is, to ask the patient what he did for a living. Or maybe he did ask but failed to take this information into account in his prescribing.

The patient was a professional racing driver. I have known several racing drivers in my career; they were all rather interesting, introverted people. The job requires athletic physical fitness combined with intense concentration; you need the ability to make split-second decisions. Yet it is quite a lonely sport – you are most of the time strapped into the cockpit of the car with little direct human interaction. The 1966 film Grand Prix shows this rather well, I think.

What is absolutely clear is that when you are driving at speeds which may exceed 300kph (186mh) there is no margin for error. Your mind must be unclouded – or the results could be fatal to yourself or to other people on the track.

Under the circumstance the antidepressant was ill-advised. Such drugs all have side effects which can include drowsiness. This may not matter too much in ordinary life but they are absolutely contraindicated (must not be used) in a racing driver! Before this treatment he was fine in the car even though he was depressed; it is in a way a meditation – when racing you cannot think of anything else than the job in hand.

The patient had been in a crash and nothing worse had happened than the severe bruising; he was lucky.

Why, oh why, did the psychotherapist take it upon herself to refer the patient on to someone else without conferring with me? Did she think, because of my well-known reluctance to use mind-drugs, so-called antidepressants, the patient was not safe in my hands? Apart from the potentially fatal outcome indirectly due to her failure to refer back to me, this was a lapse of common courtesy. Needless to say I never referred her another patient.

This incident highlights another problem that is especially evident in Japan: the lack of a general practitioner who is recognised as being in overall charge of the patient’s medical situation. What often happens is that a person independently consults specialists at different hospitals; there may be little or no communication between them. This fragmentation of care can result in reduplication of tests and treatment or inappropriate prescribing. Also, hospital doctors often work in rotating training schemes and the patient may not see the same doctor twice. If there is a query, whom should the patient approach? If there is no general practitioner, who will provide continuity of care?

Text © Gabriel Symonds

This entry was posted in Depression, Psychiatry and tagged antidepressants, professional courtesy, racing driver on November 16, 2016 by Gabriel Symonds. Edit

Depression, Busy Doctors and Winnie-the-Pooh

Depression, Busy Doctors and Winnie-the-Pooh

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pastedGraphic.pngWhenever I hear of busy doctors, I am reminded of the Bisy Backson.

If you haven’t left your childhood too far behind, you will probably know this comes from the Winnie-the-Pooh stories, specifically from the delightful book, The Tao of Pooh by Benjamin Hoff. When Rabbit went to visit Christopher Robin he found a note saying: ‘GON OUT. BACKSON. BISY. BACKSON. C.R’

Benjamin Hoff comments, ‘The Bisy Backson has practically no time at all, because he’s too busy wasting it by trying to save it.’

Now here’s an item I saw on the BBC online news (19 October 2016), so it must be true.

It’s about antidepressants.

A woman is shown in a film who says:

I was an absolute mess – wanting to take my life, like continually. I read the leaflet and I was getting exactly what it said I was getting – seizure-like symptoms where my muscles were kind of jolting around of their own accord and I felt disorientated and sick and had digestive problems and infections. I mean it’s really really extreme.

Subtitle: One in 11 British adults take antidepressants. But these pills can come with some serious side-effects.

Then we have a quote by Professor David Healy, who knows a thing or two about antidepressants – he wrote a book called Let Them Eat Prozac – and he says these pills can make many people’s problems worse:

One in four people become more anxious, rather than less. And they can become extraordinarily anxious, so that some people become very agitated and some go on from that to become suicidal.

After that, another patient, Darren, is shown. We are told he developed muscle spasms and a stammer when the dosage of his antidepressants was increased. The film shows him with violent shaking of his right arm. He says ‘I can stop it but if I do somewhere else goes’ and we can see his head and upper body start shaking.

On the other hand, Dr Sarah Jarvis, a GP in west London, says people can benefit from the right kind of antidepressant:

I think with people with severe depression, you may well need to try two or possibly three before you find one that does work. But for most people with severe depression we can find a medicine which will help them, and where the benefits will outweigh the risks.

The point of this news item is that ‘People who say their lives have been ruined by commonly prescribed antidepressants, known as SSRIs, are taking their case to Parliament on Wednesday.’

So we have opposing views from two experts on the value of antidepressants.

I think what underlies this difficult problem – do antidepressants do more harm than good? – is the concept of depression as a disease, like pneumonia or arthritis. As I have said in previous posts, depression is a symptom, not a diagnosis. What is going on with patients who are labelled as suffering from depression? It seems the common approach to mental distress is the same as with purely physical illnesses: take a history, do a physical examination if appropriate, possibly do some blood tests or an X-ray; then you can make a diagnosis and the treatment follows. For example, a patient comes with pain in the abdomen, it hurts more if the doctor presses at the lower right part, a blood test shows a raised white blood cell count, and a diagnosis of appendicitis is made; the treatment is to remove the appendix. Of course it may not be so simple as this and appendicitis can be difficult to diagnose. But how much more difficult it is with mental symptoms! The trouble, it seems to me, is that once a diagnostic label is attached the treatment that follows is a pill of one sort or another. This is a gross oversimplification.

What is going on in the mind of the patient who is diagnosed with depression? If given the opportunity in a supportive and non-judgemental setting, such patients almost invariably have plenty to say. The origin of the problem may go back to childhood, or be related to family, work or financial difficulties. A sympathetic ear can do much to ease such patients’ distress. The prescription of a so-called antidepressant can feel like a rejection: the ‘busy’ doctor – and why are doctors always busy? – doesn’t have time to go into all the patient’s troubles and issuing a script for a pill is often the quickest way to ‘dispose’ of the patient. Dispose is actually a medical term – rather unfortunate I think – for dealing with the problem that the patient brings to the doctor.

pastedGraphic_1.pngIt reminds me of when I first started to work in general practice in London in the 1960s. Computers hadn’t been invented and records were kept in what were called Lloyd-George envelopes, named after the Liberal politician who was instrumental in introducing socialised medicine into Britain. They were cards about 5 x 7 inches where one could write the clinical notes: often the entry consisted of only two words, apart from the date: a symptom and a drug. For example: ‘Tonsillitis – penicillin’, or ‘Cough – Gee’s linctus’.

In some ways this approach hasn’t changed much, except these days we use computers: Depression – Prozac.

Text © Gabriel Symonds

This entry was posted in Depression, Psychiatry and tagged antidepressants, Professor David Healy, Prozac on November 8, 2016 by Gabriel Symonds. Edit